Spotlight: Lessons Learned From 4 Decades As A Nurse Midwife

Healthcare looked very different in the 70s and 80s, especially for nurses. These were the days when female nursing students had to wear hats, dresses, and stockings, and healthcare care was a paternalistic system dominated by physicians.

“When people went to a doctor’s office, there were hardly any nurse practitioners. The doctor knew best and was going to tell you what he thought was right for you. If you weren’t married, he might give you some judgment about it. He may not even provide you with birth control. It was a very different time.”

The Beginning of Big Changes

Mary Barnett attended an early gynecology program at the University of Texas graduate school, and a decade later also graduated from nurse midwifery school in 1980 .

Though she’s founded three practices in her career (Austin Area Nurse Midwifery Service, Second Nature Women’s Health Care and Heart of Texas Midwives), Mary didn’t start out as a midwife or an entrepreneur.

She first put her nursing education to work doing gynecology at the People’s Community Clinic in Austin.

During the years she worked there, Mary wasn’t just serving her patients at a high level. She was participating in a feminist women’s health movement.

“People’s Community Clinic was a hotbed of creativity at that time. We gave all our patients a copy of Our Bodies, Ourselves, which was inexpensive because it was printed on newsprint. This book was all about options for birth control, childbirth, menopause, and more. I wanted to share what I knew with other women.”

Working on behalf of all women – both patients and colleagues – was half of Mary’s motivation for becoming a nurse midwife.

“Part of my passion is for my patients. The other part is for the profession. Coming from a nursing education in the 1970s, women’s liberation has been incredibly important to me. I’ve done most of my work with other midwives, but I’ve also had nurse practitioner students over the years. I try to help them see the profession another way.

A Broken System

After Mary graduated from Nurse Midwifery school, she became an entrepreneur out of necessity – she had no other choice.

“There were no practice options for midwives within a large radius around Austin. My only other choice was to work in a hospital as a labor and delivery nurse.”

Mary knew going into midwifery school her options would be limited after graduating, but that wasn’t going to stop her from doing what she was meant to do.

“I wasn’t thinking of a business plan. I went to midwifery school because I had a passion and I knew if I didn’t do it, I wasn’t going to be true to myself.”

Mary and her co-owners faced numerous challenges as nurse midwives in the 1980s, chief among them the difficulty of getting patients the medication they needed without prescriptive authority.

“Prescriptive authority was the biggest issue. To call in prescriptions, it was implied you had to be the employee of a physician or the employee of an institution where the physician was privileged. We were neither.”

Today, nurse practitioners in Texas must have a prescriptive authority agreement with a physician that requires them to meet once a month and often pay the physician a fee, which can be thousands per month. This is an obstacle to NPs starting their own practice in Texas. But in the 1980s, that obstacle was far more daunting.

“All these advanced practice nurses who can prescribe fairly easily are standing on the hard work and accomplishments of a lot of other advanced practice nurses.”

As a newly minted business owner, Mary also found herself facing the daunting task of submitting claims to insurance companies that severely devalued her services. This problem hasn’t disappeared during the past forty years. In fact, it became such an encumbrance that Mary no longer accepts insurance at her current practice.

“Having my own practice and doing home births, which I did for at least a dozen years, insurance just doesn’t want to pay what we’re worth. I hate to say it, but I think it’s built in sexism in medicine. A cardiologist gets more money for an office visit where he reads an EKG than an obstetrician who reads a fetal monitor during a prenatal visit. It’s not equal, and when you put a midwife into the equation, it goes down even more.”

To put things in perspective,  recently a client’s insurance provider accidentally sent Mary the client’s negotiation for payment. For a ninety-minute visit with a sixty-year-old patient, the company wanted to pay the client $35.

Politically Active

This is the type of disrespect and injustice that Mary believes should drive nurses to become politically active. In her younger years, Mary was involved with the Coalition for Nurses in Advance Practice (CNAP) and served on the board for six years.

“If you’re not at the table, you’re on the menu. If you don’t show up, other people are going to make decisions about your professional life. If I could instill anything into young nurses, it’s to get involved and do what you can. Meet your elected officials and support those people who support our issues. If feel called, run for office.”

There’s a major push in Texas right now for APNs to gain full practice authority, which is an issue that Mary believes can be achieved from various angles.

“We just have to keep suiting up and showing up. One of the other sayings I learned in doing the political work is it’s about relationships. You must get out and talk to people. Talk to your representatives but also talk to your clientele. As a midwife, when our clients come for their six-week post-partum checkup, we hand them a postcard and ask if they’d send it to their legislator in support of the midwifery model of care.”

Nurse midwives are facing their own political battles. The relationship they’re forced into with a collaborating physician is rife with conflicts of interest, and better options exist.

“Being dependent on obstetricians to support us, well, they’re our competition in a way. I think the ideal model is for obstetricians to be the specialists, the ones who manage the people who are really sick or have complications. For most births, if women and babies are taken care of by midwives, it’s been proven to decrease surgery and NICU admissions, which reduces costs. But those are big money makers for hospitals, so there’s a disincentive for institutions to reduce those costs.”

For the time being, APNs living in a restricted state and looking to start their own practice should look for collaborating physicians with whom they can build a respectful, mutually beneficial relationship.

“It’s about genuine relationships. I didn’t cultivate relationships trying to look for a delegating physician. It was about connecting with people that I respected, and who, over time, came to respect me.”

It’s All Worth It

For all its challenges, owning a practice has been immensely gratifying for Mary in several ways. While she would be the first to admit her business hasn’t made her rich, Mary has found immeasurable satisfaction, enjoyment, and accomplishment that comes from impacting the lives of women and their families. She’s also proud that she built a business with a flexible schedule that allowed her to raise her three children.

APNs worried about the cost of building a patient base should know that Mary has grown her business organically through word of mouth and with minimal marketing expense.

“I think if somebody wanted to grow a business like mine they could. I tend to grow organically. I like to get the majority of clientele by word of mouth, even if it’s word of mouth on social media, somebody who knows me recommending me.”

The advice she would give to entrepreneurial APNs is simple: don’t go it alone.

“Find some other people in practice that you respect. It could be a doctor, but ideally it’s an advanced practice nurse you can talk to on a regular basis. Don’t be isolated. No person is an island, so even if you have your own practice, you have to refer to other people, so make your community, make your tribe. You don’t have to call it a mentoring thing. Just find some other people you can bounce things off of.”

Advice for Nurse Owners Today

Whatever APNs know about business when they begin their practice, the one thing they can control from the beginning is the quality of care they provide. In Mary’s eyes, this is an area where there’s no room for compromise – exceptional care is the expectation.

“In terms of patient care, I would say to follow standards. Don’t cut corners with that because quality of care speaks more loudly than anything else. As nurse midwives, we were always encouraged to keep our own outcome statistics so that you can share them with others [i.e. legislators, insurance companies, etc]”

Her final piece of advice is born from years of navigating the world of entrepreneurship while trying to be the best midwife she could be. It’s advice that’s been hard earned over a long career and speaks to Mary’s belief in the power of community.

“You don’t have to have everything figured out when you start. In fact, you won’t. Even if you had a book or website with instructions, there’s always going to be stuff that comes up that you hadn’t thought of or you’re not ready for. And that’s where those other friends help, as does being part of a supportive community of peers.”